<cfparam name="PARAMS.isPDF" default="false">
<cfparam name="PARAMS.debug" default="false">
<cfoutput>
	#dspDocumentHeader()#
	<!--- <cfsavecontent variable="Document"> --->
	<h2>Eligibility, Referral, and Admission Form</h2>
	<cfform type="html/xform">
		<cfformgroup label="Part I: Basic Information " type="panel">
			<cfif PARAMS.key NEQ 0>#dspFormButtons(key=PARAMS.key, action=PARAMS.controller)#</cfif>
			<!--- DOCUMENT PART 1 --->
			<fieldset>
				<legend class="title">Part 1: Basic Information <span class="caption">COMAR 10.21.17.08 B(1)(a-c)</span></legend>
					<table width="100%" cellpadding="6">
						<tr>
							<!--- Consumer Name --->
							<td class="formLabel">Consumer Name:</td><td>#document.consumerName#</td>
							<!--- Consumer ~ Gender --->
							<td class="right" valign="middle">Gender:</td>
							<td>									
								<div class="radiobutton">
									#radioButtonTag(id="#PARAMS.key#-gender-1", class="validate[required]", name="#PARAMS.key#[gender]", value="1", label="Male ")#
									#radioButtonTag(id="#PARAMS.key#-gender-2", class="validate[required]", name="#PARAMS.key#[gender]", value="2", label="Female ")#
								</div>
							</td>
							<td></td>
						</tr>
						<tr>
							<!--- Social Security Number --->
							<td class="formLabel">Social Security Number:</td>
							<td class="left">#dspSSN()#</td>
							<!--- Referral Table --->
							<td class="formLabel" colspan="2" rowspan="6">
								<table class="forms" width="500px" height="100%"  cellpadding="6">
									<tr class="title"><th colspan="2">Source of Referral <span class="caption">COMAR 10.21.17.08 B(4)</span></th></tr>
									<tr>
										<td class="formLabel">Referred By:</td>
										<td class="left">#textFieldTag(id="#PARAMS.key#-referredBy", class="validate[custom[number]] normal1", name="#PARAMS.key#[referredBy]", value=document.referredBy, maxlength="30")#</td>
									</tr>
									<tr>
										<td  class="formLabel">Credentials:</td>
										<td  class="left">#textFieldTag(id="#PARAMS.key#-referralCredentials", class="validate[custom[number]] normal1", name="#PARAMS.key#[referralCredentials]", value=document.referralCredentials, maxlength="50")#</td>
									</tr>
									<tr class="title"><th colspan="2">Agency Name & Address</th></tr>
									<tr>
										<td class="formLabel">Agency Name:</td>
										<td class="left">#textFieldTag(id="#PARAMS.key#-referralName", class="validate[custom[number]] normal1", name="#PARAMS.key#[referralName]", value=document.referralName, maxlength="30")#</td>
									</tr>
									<tr>
										<!--- Referral ~ Address --->
										<td class="formLabel" valign="top">Agency Address:</td>
										<td class="left" valign="top">#dspAddress("referral")#</td>
									</tr>
									<tr>
										<!--- Agency ~ Phone Number --->
										<td  class="formLabel">Agency Phone:</td>
										<td  class="left">#dspPhoneNumber("referral")#	</tr>
								</table>
							</td>
						</tr>
						<tr>
							<!--- Consumer ~ Date of Birth --->
							<td  class="formLabel">Date of Birth:</td>
							<td  class="left">#textFieldTag(id="#PARAMS.key#-dateOfBirth", class="validate[custom[number]] date", name="#PARAMS.key#[dateOfBirth]", value=document.dateOfBirth)#</td>
						</tr>
						<tr>
							<!--- Consumer ~ Address --->
							<td class="formLabel" valign="top">Address:</td>
							<td class="left" valign="top">#dspAddress()#</td>
						</tr>
						<tr><td colspan="2" align="center"><hr /></td></tr>
						<tr>
							<!--- Employer Name --->
							<td class="formLabel">Employer:</td>
							<td class="left">#textFieldTag(id="#PARAMS.key#-employer", class="large", name="#PARAMS.key#[employer]", value=document.employer, maxlength="30")#</td>
						</tr>
						<tr>
							<!--- Employer ~ Address --->
							<td class="formLabel" valign="top">Employer Address:</td>
							<td class="left" valign="top">#dspAddress("employer")#</td>
						</tr>
						<tr><td colspan="2" align="center"><hr /></td><td colspan="2"></td></tr>
						<tr>
							<!--- Emergency Contact Name --->
							<td class="formLabel" nowrap="true">Emergency Contact: <div class="caption">COMAR 10.21.17.08 B(2)</div></td>
							<td class="left clear" valign="top">#textFieldTag(id="#PARAMS.key#-emergency", class="validate[custom[number]] large", name="#PARAMS.key#[emergency]", value=document.emergency, maxlength=30)#</td>
							<td class="formLabel">Phone Number:</td>
							<td class="left">#dspPhoneNumber("emergency")#</td>
						</tr>
						<tr>
							<td class="formLabel">Address:</td>
							<td colspan="3">#dspAddress("emergency")#</td>
						</tr>
					</table>
				</fieldset>
		</cfformgroup>
		
		<!--- DOCUMENT PART 2 --->
		<fieldset>
			<legend class="title">Part II: Diagnosis</legend>				
			<table padding="6">
				<tr>
					<td class="formLabel" valign="top">Axis 1<br /><div class="caption">COMAR 10.21.26.05 B(b)(i), <br />COMAR 10.21.26.05 A(1)(a)(i-ii)</div></td>
					<td class="left clear" valign="top">
						#dspAxisCodes()#<br />
						#textFieldTag(id="#PARAMS.key#-axis1", class="validate[custom[number]] small", name="#PARAMS.key#[axis1]", value=document.axis1)#							
					</td>
				</tr>
				<tr>
					<td class="formLabel clear">Current GAF:</td>
					<td  class="formLabel left clear">#textFieldTag(id="#PARAMS.key#-currentGAF", class="validate[custom[number]] small", name="#PARAMS.key#[currentGAF]", value=document.currentGAF)#</td>
				</tr>
				<tr>
					<td class="formLabel">Highest GAF in Last Year:</td>
					<td  class="formLabe left clear">#textFieldTag(id="#PARAMS.key#-highestGAFInLastYear", class="validate[custom[number]] small", name="#PARAMS.key#[highestGAFInLastYear]", value=document.highestGAFInLastYear)#</td>
				</tr>
			</table>
			
			<dl>
				<dt>
						<strong>#document.consumerName#</strong> has been evaluated by 
						#textFieldTag(id="#PARAMS.key#-evaluatedBy", class="large", name="#PARAMS.key#[evaluatedBy]", value=document.evaluatedBy)# 
						(Physician or Licensed Mental Health Professional) <span class="caption">COMAR 10.21.26.05 B(1)</span> and is in need of Crisis Residential Services in order to:
				</dt>
				<dt>
					<span class="formInput">#dspRadioButton("durationOfHospitalization", "validate[required]", "1")#</span>
					<span class="formLabel">Avoid Inpatient Hospitalization (The individual is experiencing a psychiatric crisis and is at risk for harming themselves and others without the level of care provided by an RCS), <span class="caption">COMAR 10.21.26.03 A(3)(a), COMAR 10.21.26.04 B(1)(a-b)</span>.</span>
				</dt>
				<dt>
					<span class="formInput">#dspRadioButton("durationOfHospitalization", "validate[required]", "2")#</span>
					<span class="formLabel">Shorten Inpatient Hospitalization (The individual has been evaluated by a physician or licensed mental health professional, and presents a danger to self or others and without RCS, would not be discharged from the inpatient facility), <span class="caption">COMAR 10.21.6.03 A(3)(b), COMAR 10.21.26.04 B(2)(a-b)</span>.</span>
				</dt>
			</dl>
		</fieldset>
		
		<!--- DOCUMENT PART 3 --->
		<fieldset>
			<legend class="title">Part III: Detail of Symptoms</legend>				
			<h4>Please fill out all the questions</h4>
			<ol>
				<li>
					<p>List current symptoms that lead consumer to being at risk? Please be specific. <br /><span class="caption">COMAR 10.21.26.05 A(1)(iii)</span></p>
					#textAreaTag(id="#PARAMS.key#-symptoms", class="normal", name="#PARAMS.key#[symptoms]", content=document.symptoms)#
				</li>
				<li>
					<p>What specific factors contributed to the current crisis?<br /><span class="caption">COMAR 10.21.26.05 A(1)(iii), COMAR 10.21.17.08 B(8)</span></p>
					#textAreaTag(id="#PARAMS.key#-factors", class="normal", name="#PARAMS.key#[factors]", content=document.factors)#
				</li>
			</ol>
		
			<cfset eligibilityList = [
				'Requires separation from living situation due to symptoms of illness, <br /><span class="caption">COMAR 10.21.26.05 A(1)(iv)</span>',
				'Willing to comply with all programs rules,<br /><span class="caption">COMAR 10.21.26.05 A(1)(v)</span>',
				'Expects, with staff support, to be able to comply with treatment recommendations,<br /><span class="caption">COMAR 10.21.26.05 A(1)(vi)</span>',
				'Can and will complete ADL''s independently, with staff support,<br /><span class="caption">COMAR 10.21.26.05 A(1)(vii)</span>'
				]>
		
			<dl>
				<dt>Eligibility Checklist (<strong>All</strong> must be checked)</dt>
				<cfloop from="1" to="#ArrayLen(eligibilityList)#" index="intRow">
					<dt class="list">#dspCheckbox("eligibility", eligibilityList[intRow], intRow)#</dt>
				</cfloop>
			</dl>
			
			<h4>Current Symptoms of Mental Illness</h4>
		
			<cfset symptoms = {
					'psychosis' = ["Auditory/Visual","Delusions","Paranoia","Guarged/Suspicious"],
					'depression' = ["Hopeless/Helpless","Lack of Energy","Change in Sleep/Appetite"],
					'mania' = ["Grandiose","Extreme Irritability","Inappropriate Social Behavior"],
					'thoughts' = ["Confused","Disoriented","Slow to Process","Impaired Reality Testing"],
					'other' = []																								
				}>

			<dl>
				<cfloop collection="#symptoms#" item="type">
					<dt>#titleize(type)# <cfif ArrayLen(symptoms[type]) EQ 0>#textFieldTag(name="#PARAMS.key#[#type#]", value="#document['#type#'][1]#")#</cfif></dt>
					<cfloop from="1" to="#ArrayLen(symptoms[type])#" index="intRow">
						<dt class="list">#dspCheckbox(type, symptoms[type][intRow], intRow)#</dt>
					</cfloop>
				</cfloop>
			</dl><br />
			
			<table width="600px">
				<tr>
					<td width="250px" class="formLabel">Current Suicidal/Homicidal Ideation:</td> 
					<td width="50px">&nbsp;</td>
					<td width="350px" class="left">
						<div class="radiobutton">
							#dspRadioButton("isSuicidalHomicidal", "validate[required]", "0", "No")#
							#dspRadioButton("isSuicidalHomicidal", "validate[required]", "1", "Yes")#
						</div>
					</td>
				</tr>
				<tr>
					<td class="formLabel">Current Symptoms:</td>
					<td width="50px">&nbsp;</td>
					<td class="left">
						<div class="radiobutton">
							#dspRadioButton("symptomLevel", "validate[required]", "1", "Severe")#
							#dspRadioButton("symptomLevel", "validate[required]", "2", "Intense")#
							#dspRadioButton("symptomLevel", "validate[required]", "3", "Moderate")#
						</div>							
					</td>
				</tr>
			</table>

			<h4>Mental Health Treatment, <span class="caption">COMAR 10.21.26.06 A(2)(a)</span></h4>
			
			<cfset hospitalizationHistory = ["pastMonth", "pastYear", "past5Years"]>
			<dl>
				<dt>Current/Past Hospitalizations</dt>
				<cfloop array="#hospitalizationHistory#" index="label">
					<dt class="list">
						#Replace(humanize(label), "5", " 5")# #textFieldTag(name="#PARAMS.key#[#label#]", value=document['#label#'][1])#
					</dt>
				</cfloop>
				<dt>
					Current Outpatient Providers 
					#dspAddButton(2, '<dt class="list">[D]</dt>')#
			    </dt>
				<cfset outpatients = ListToArray(ValueList(document.outpatientProvider))>
				<cfloop array="#outpatients#" index="provider">
					<cfif provider IS NOT "">
						<dt class="list">#textFieldTag(name="#PARAMS.key#[#outpatientID#][outpatientProvider]", value=provider)#</dt>
					</cfif>
				</cfloop>
			</dl>
		</fieldset>
		
		<!--- DOCUMENT PART 4 --->
		<fieldset>
			<legend class="title">Part IV: Medications</legend>				
			<h4>Substance Abuse, <span class="caption">COMAR 10.21.17.08 B(8)</span></h4>
			<table cellpadding="4">
				<tr>
					<td width="200px" class="formLabel">Currently Abusing:</td>
					<td class="350px" class="left">
						<div class="radiobutton">
							#dspRadioButton('isSubstanceAbuse', 'validate[required]', '0', 'No')#
							#dspRadioButton('isSubstanceAbuse', 'validate[required]', '1', 'Yes')#
						</div>
					</td>
				</tr>
				<tr>
					<td class="formLabel">Last Use Date:</td>
					<td class="left">#textFieldTag(id="#PARAMS.key#-lastSubstanceUse", class="validate[custom[date]] date", name="#PARAMS.key#[lastSubstanceUse]", value=document.lastSubstanceUse)#</td>
				</tr>
				<tr>
					<td class="formLabel">Frequency of Use:</td>
					<td class="left">#textFieldTag(id="#PARAMS.key#-frequencySubstanceUse", class="validate[custom[number]]", name="#PARAMS.key#[frequencySubstanceUse]", value=document.frequencySubstanceUse, maxlength="3")#</td>
				<tr>
			</table>
		
			<h4>Physical Health</h4>
			
			<table cellpadding="4">
				<tr>
					<td  width="200px" class="formLabel">Current Medical Conditions:</td>
					<td  width="350px" class="left">#textFieldTag(id="#PARAMS.key#-currentPhysicalCondition", name="#PARAMS.key#[currentPhysicalCondition]", value=document.currentPhysicalCondition, maxlength="100")#</td>		
				</tr>
				<tr>
					<td  class="formLabel">Current Monitoring Needs:<br />(Diabetes, HTN)</td>
					<td  class="left">#textFieldTag(id="#PARAMS.key#-currentMonitoringNeeds", name="#PARAMS.key#[currentMonitoringNeeds]", value=document.currentMonitoringNeeds, maxlength="100")#</td>
				</tr>
				<tr>
					<td  class="formLabel">Is the consumer medically stable?</td>
					<td  class="left">
						<div class="radiobutton">
							#dspRadioButton('isStable', 'validate[required]', '0', 'No')#
							#dspRadioButton('isStable', 'validate[required]', '1', 'Yes')#
						</div>
					</td>
				</tr>
				<tr>
					<td  class="formLabel">Allergies</td>
					<td  class="left">#textFieldTag(id="#PARAMS.key#-allergies", name="#PARAMS.key#[allergies]", value=document.allergies, maxlength="100")#</td>
				</tr>
			</table>
			
			<h4>Medications, <span class="caption">COMAR 10.21.26.05 B(b)(ii)</span></h4>

			<cfset medicationsType1 = filterThrough("medicationType, medicationDosage, medicationFrequency, medicationID", document, "medicationType = 1")>
			<cfset medicationsType2 = filterThrough("medicationType, medicationDosage, medicationFrequency, medicationID", document, "medicationType = 2")>
			
			<cfset medications = [
				{ label = "Current Psychotropic Medications (Dosage & Frequency)", value="1", results=medicationsType1 },
				{ label = "Current Somatic Medications (Dosage & Frequency)", value="2", results=medicationsType2 }					
			]>
			
			<cfloop array="#medications#" index="medicationType">
				<table class="forms">
					<tr>
						<th class="transparent" colspan="2">#medicationType.label#</th>
						<th class="transparent"></th>
					</tr>
					<tr>
						<th class="title">Dosage</th>
						<th class="title">Frequency</th>
						<th class="transparent">
							<div class="btn-group" style="margin: 9px 0;">
								<a class="btn btn-info btn-single addButton" title="Add User">
									<i class="icon-plus icon-white"></i>
								</a>
							</div>
						</th>
					</tr>
					<cfloop query="medicationType.results">
						<tr>
							<td>#textFieldTag(id="#PARAMS.key#-#medicationType.value#-medicationDosage", name="#PARAMS.key#[#medicationType.value#][medicationDosage]", value=medicationDosage)#</td>
							<td>#textFieldTag(id="#PARAMS.key#-#medicationType.value#-medicationFrequency", name="#PARAMS.key#[#medicationType.value#][medicationFrequency]", value=medicationFrequency)#</td>
							<td class="transparent">
								<div class="btn-group" style="margin: 9px 0;">
									<a class="btn btn-info btn-single deleteButton" title="Delete User">
										<i class="icon-trash icon-white"></i>
									</a>
								</div>
							</td>
						</tr>
					</cfloop>
				</table><br />
			</cfloop>
		
			<h4>Securing Medications for the CRS</h4>

			<cfif isDate(document.medicationDeliveryDate)>
				<cfset medicationDeliveryDate = document.medicationDeliveryDate>
			<cfelse>
				<Cfset medicationDeliveryDate = "">
			</cfif>
			<dl>
				<dt>Consumer with Medical Assistance (MA)</dt>
				<dt class="list">
					<span class="formInput">#dspRadioButton("medicationMethod", "validate[required]", "1")#</span>
					<span class="formLabel">Prescriptions are filled</span>
				</dt>
				<dt class="list">
					<span class="formInput">#dspRadioButton("medicationMethod", "validate[required]", "2")#</span>
					<span class="formLabel">Prescriptions were faxed to #textFieldTag(id="#PARAMS.key#-1-medicationDeliveryName-1", name="#PARAMS.key#[1][medicationDeliveryName]", value=document.medicationDeliveryName)# pharmacy at 
						#textFieldTag(id="#PARAMS.key#-1-medicationDeliveryDate-1", name="#PARAMS.key#[1][medicationDeliveryDate]", value=medicationDeliveryDate)#
						#dspAmPm()#
					</span>
				</dt>
				<dt>&nbsp;</dt>
				<dt>Consumer with <strong>No</strong> Insurance</dt>
				<dt class="list">
					<span class="formInput">#dspRadioButton("medicationMethod", "validate[required]", "1")#</span>
					<span class="formLabel">Arriving with 3 days of medications</span>
				</dt>
				<dt class="list">
					<span class="formInput">#dspRadioButton("medicationMethod", "validate[required]", "2")#</span>
					<span class="formLabel">
						PAC application faxed to CORE and Verified By #textFieldTag(id="#PARAMS.key#-2-medicationDeliveryName-1", name="#PARAMS.key#[2][medicationDeliveryName]", value=document.medicationDeliveryName)#
					</span>
				</dt>
			</dl>
		</fieldset>
		
		<fieldset>
			<legend class="title">Part V: Authorization</legend>
	
			<table class="forms2" align="center" cellpadding="6">			<!--- Date Format: MM/DD/YY – MM/DD/YY --->
				<tr>
					<td  class="formLabel">Physician Signature/Credentials, <div class="caption">COMAR 10.21.17.08 A(1)(b)</div></td>
					<td  class="left">#textFieldTag(d="#PARAMS.key#-physicianSignature", name="#PARAMS.key#[phsyicianSignature]", value=document.physicianSignature, maxLength="30")#</td>
					<td  class="left">Date #textFieldTag(id="#PARAMS.key#-physicanSignatureDate", name="#PARAMS.key#[physicanSignatureDate]", class="validate[custom[date]] date",  value=document.physicianSignatureDate)#</td>
				</tr>
				<tr>
					<td  class="formLabel">Referrer's Signature/Credentials, <div class="caption">COMAR 10.21.17.08 A(1)(b)</div></td>
					<td  class="left">#textFieldTag(d="#PARAMS.key#-referrerSignature", name="#PARAMS.key#[referrerSignature]", value=document.referrerSignature, maxLength="30")#</td>
					<td  class="left">Date #textFieldTag(id="#PARAMS.key#-referrerSignatureDate", name="#PARAMS.key#[referrerSignatureDate]", class="validate[custom[date]] date",  value=document.referrerSignatureDate)#</td>
				</tr>
				<tr>
					<td  class="formLabel">Consumer's Signature</td>
					<td  class="left">#document.consumerName#</td>
					<td  class="left">Date #textFieldTag(id="#PARAMS.key#-consumerSignatureDate", name="#PARAMS.key#[consumerSignatureDate]", class="validate[custom[date]] date",  value=document.consumerSignatureDate)#</td>
				</tr>
			</table>
		
			<h4>Insurance Approval (<span class="caption2"><strong>Value Options</strong>: 1(800) 888 1965; Provider Code 644290</span>):<br /><span class="caption">COMAR 10.21.26.05 A(1)(b)</span></h4>
		
			<table  cellpadding="6">
				<tr>
					<td  class="formLabel">Medical Assistance ##</td>
					<td  class="formLabel">#textFieldTag(id="#PARAMS.key#-medicalAssistanceID", name="#PARAMS.key#[medicalAssistanceID]", value=document.medicalAssistanceID, class="numeric", maxLength="15")#</td>
					<td  class="formLabel">## of Days Authorized</td>
					<td  class="left clear">#textFieldTag(id="#PARAMS.key#-numberOfDaysAuthorized", class="validate[custom[number]] numeric", name="#PARAMS.key#[numberOfDaysAuthorized]", value=document.numberOfDaysAuthorized)#</td>
				</tr>
				<tr>
					<td  class="formLabel">Initial Authorization ##</td>
					<td  class="formLabel">#textFieldTag(id="#PARAMS.key#-initialAuthorizationID", name="#PARAMS.key#[initialAuthorizationID]", class="numeric", value=document.initialAuthorizationID, maxLength="15")#</td>
					<td  class="formLabel">Dates Approved</td>
					<td  class="formLabel">
						#textFieldTag(id="#PARAMS.key#-initialDateStart", class="validate[custom[date]] date", name="#PARAMS.key#[initialDateStart]", value=document.initialDateStart)#
						<strong> - </strong>
						#textFieldTag(id="#PARAMS.key#-initialDateEnd", class="validate[custom[date]] date", name="#PARAMS.key#[initialDateEnd]", value=document.initialDateEnd)#
					</td>
				</tr>
				<tr>
					<td  class="formLabel">Exension Authorization ##</td>
					<td  class="formLabel">#textFieldTag(id="#PARAMS.key#-extensionAuthorizationID", class="validate[custom[number]] numeric", name="#PARAMS.key#[extensionAuthorizationID]", value=document.extensionAuthorizationID, maxLength="15")#</td>
					<td  class="formLabel">Dates Approved</td>
					<td  class="formLabel">
						#textFieldTag(id="#PARAMS.key#-extensionDateStart", class="validate[custom[date]] date", name="#PARAMS.key#[extensionDateStart]", value=document.extensionDateStart)#
						<strong> - </strong>
						#textFieldTag(id="#PARAMS.key#-extensionDateEnd", class="validate[custom[date]] date", name="#PARAMS.key#[extensionDateEnd]", value=document.extensionDateEnd)#
					</td>
				</tr>
				<tr>
					<td  class="formLabel">Agent Authorizing ##<div class="caption">(For SJH Staff if Needed)</div></td>
					<td colspan="3">#textFieldTag(id="#PARAMS.key#-agentAuthorizing", class="validate[custom[number]] numeric", name="#PARAMS.key#[agentAuthorizing]", value=document.agentAuthorizing, maxLength="15")#</td>
				</tr>
			</table>
			
			<hr style="width: 100%;"/>

			<h4><em>*SJH STAFF USE ONLY*</em></h4>
			
			<p>
				<span>Staff accepting consumer's entrance to SJH: #textFieldTag(id="#PARAMS.key#-staffAuthorizing", name="#PARAMS.key#[staffAuthorizing]", value=document.staffAuthorizing, maxLength="30")#</span>
				<span style="padding-left: 2em;">Date: #textFieldTag(id="#PARAMS.key#-staffAuthorizingDate", class="validate[custom[date]] date", name="#PARAMS.key#[staffAuthorizingDate]", value=document.staffAuthorizingDate)#</span>
			</p>
			
			<ol>
				<li>
					Complete any Section of the form (with the referring party) not already completed.<br />
					<div class="caption">(Contact referrer to thank them for referral and ask the following question)</div>
					<dl>
						<dt>
							What have been the biggest challenges to treatment for this individual?<br />
							#textAreaTag(id="#PARAMS.key#-staffQ1", class="normal", name="#PARAMS.key#[staffQ1]", value=document.staffQ1)#
						</dt>
					</dl>
				</li>
				<li>Verify that <strong>all</strong> of the consumer's medication arrives within 24 hours.
					<dl>
						<cfset verification = [
								"CVS/Walmart/CARE/FlexCare/Other",
								"PAC application is verified by CSA",
								"PAC application NEEDS to be sent to Baltimore for approval",
								"PAC application is verified by CSA"	
							]>				
						<cfloop from="1" to="#ArrayLen(verification)#" index="intRow"> 
							<dt>#dspCheckbox("staffQ2", verification[intRow], intRow)#</dt>
						</cfloop>
					</dl>
				</li>
				<li>Somatic Conditions: #textFieldTag(id="#PARAMS.key#-staffQ3", name="#PARAMS.key#[staffQ3]", value=document.staffQ3)#
					<dl>
						<dt>
							Conditions need to be monitored:
							<span class="radiobutton">
								#radioButtonTag(name="staffQ3-1", value="0", label="No")#
								#radioButtonTag(name="staffQ3-2", value="1", label="Yes")#
							</span>								
						</dt>
						<dt class="list"> If <strong>Yes</strong>, Please Specify:</dt>
						<dt class="list">
							Method<br />#textAreaTag(id="#PARAMS.key#-staffQ3_method", name="#PARAMS.key#[staffQ3_method]", class="normal", value=document.staffQ3_method)#
						</dd>
						<dt class="list">
							Frequency<br />#textAreaTag(id="#PARAMS.key#-staffQ3_frequency", name="#PARAMS.key#[staffQ3_frequency]", class="normal", value=document.staffQ3_frequency)#
						</dd>
					</dl>
				</li>
				<li>Verify Documentation
					<dl>
						<cfset documentationVerification = [
								'Lab work<span class="caption"> (blood levels for consumers on Depakote/ Lithium/Clozaril)</span>',
								"Admission/Discharge Summary",
								"Psychiatric Evaluation",
								"Psychosocial"
							]>
							
							<cfloop from="1" to="#ArrayLen(documentationVerification)#" index="intRow">
								<dt>#dspCheckbox("staffQ4", documentationVerification[intRow], intRow)#</dt>
							</cfloop>
					</dl>
				</li>
				<li>
					<span>Date of Arrival: #textFieldTag(id="#PARAMS.key#-arrivalDate", class="date", name="#PARAMS.key#[arrivalDate]", value=document.arrivalDate)#</span>
					<span style="padding-left: 2em;">Reviewed/Approved By: #textFieldTag(id="#PARAMS.key#-approvedBy", name="#PARAMS.key#[approvedBy]", value=document.approvedBy)#</span>
				<li>
					Consumer Cell Phone Number: 
					#dspPhoneNumber()#
				</li>
			<ol>
		</fieldset>
	</cfform>
	<cfif PARAMS.key NEQ 0>#dspFormButtons(PARAMS.key)#</cfif>
<!--- 	</cfsavecontent> --->

<!--- 	<cfset FormKeys = StructKeyArray(Form)>
	<cfset ArraySort(FormKeys, "text", "asc")> --->

<!--- 	<cfif PARAMS.isPDF>
		<cfdocument format="pdf">
			<cfloop array="#FormKeys#" index="Section">
			<!--- 	<cfdocumentsection name="#Titleize(Section)#"> --->
						#Form[Section]#
<!--- 				</cfdocumentsection> --->
			</cfloop>
		</cfdocument>
	<cfelse>
		<cfloop array="#FormKeys#" index="Section">
			#Form[Section]#
		</cfloop>
	</cfif> --->
<!--- #Document# --->
</cfoutput>